Guest Editorial
Improving support for doctors in the UK:
The development of a modified physician assistant
model in primary care and internal medicine
Nigel Sparrow, Mayur Lakhani
Introduction
In the United Kingdom, there has been a demand over the
last few years to increase the workforce in both primary and
secondary care to meet the requirements of the government’s
ambitious plan for the National Health Service.1 The NHS plan
stated that staffing constraints rather than lack of funding, posed
the greatest threat to NHS modernisation. There is a shortage
of doctors in the UK. As a result there has been a development
of new and extended roles. In this article we wish to describe
the development of a new health care worker called the medical
care practitioner based on the physician assistant model that is
commonly found in the USA.
It is with this background that the medical care practitioner
role has been developed. There is an undoubted need to increase
the range and flexibility of the NHS workforce as outlined in the
NHS Plan 2000.1 The medical care practitioner role will attract
people who would not have previously considered working in
the NHS. The Royal College of General Practitioners and the
Royal College of Physicians have worked closely together to
develop this new role and define the standards for education
and training. The two colleges have worked with the NHS to
develop a competence and curriculum framework for medical
care practitioners. This document has now been released for
public consultation.4
Physician Assistants
Definition of a medical care practitioner
During the 1960’s physician assistants were developed in
the United States to “relieve a nationwide shortage of doctors
in primary care and to increase access to health care for people
in under-served areas.”2 Physician assistants undergo 2 years of
intensive training after a first degree and must pass a national
certifying examination. They also have to complete 100 hours
of continuing education every 2 years and pass a re-certification
examination every 6 years.3
Recently several NHS organisations in primary and
secondary care in the UK have developed new posts to address
problems of workload. This has often been a localised response
to address a particular local need. Their duties vary from
mainly administrative tasks to detailed clinical work previously
undertaken by registered health professionals. The titles of
these new posts vary, leading to confusion and lack of clarity of
roles and responsibilities. This is a very unsatisfactory situation
with a multitude of unregulated practitioners providing care for
patients with varying degrees of supervision.
Keywords
Medicine, physician assistant
Nigel Sparrow FRCGP *
Vice- Chairman, RCGP and Visiting Professor
General Practice, University of Lincoln, UK
Email: Nigel.Sparrow@nottingham.ac.uk
Mayur Lakhani FRCP (Edin) FRCGP
Chairman of Council, RCGP, London, UK
Email: mlakhani@rcgp.org.uk
*corresponding author
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The medical care practitioner role has been developed from
the physician assistant model in the United States and is defined
as “a new healthcare professional who, while not a doctor, works
to the medical model, with the attitudes, skills and knowledge
base to deliver holistic care and treatment within the general
medical and/or general practice team under defined levels of
supervision.” 4
Benefits of medical care practitioners
In primary care, the development of the medical care
practitioner role provides an opportunity to improve and
develop the skill mix in health care teams, whilst emphasising
the unique skills and knowledge of general practitioners who are
highly skilled professionals with expertise in managing patients
with complex co-morbidities and the evaluation of unselected,
undifferentiated problems. When developing a new role, such
as the medical care practitioner, it is important to recognise
the skills of other health care professionals so that patients are
treated safely, effectively and with equality.
The competence and curriculum framework for medical
care practitioners describes the role of this new health care
professional who will work under the supervision of a doctor.
The document outlines the standards, education and assessment
of medical care practitioners enabling qualification from a UK
university. It outlines the knowledge, skills and core competences
expected at qualification and it is anticipated that a fully trained
medical care practitioner will deliver care and treatment at the
level of a junior doctor in their second foundation year.
What will medical care practitioners do?
A medical care practitioner will be able to perform many
tasks which are currently carried out by doctors, enabling
doctors to be able to concentrate on the complex problems which
require the particular skills and knowledge of a GP or hospital
Malta Medical Journal Volume 18 Issue 01 March 2006
consultant. The medical care practitioner will be able to:
• Take a detailed history, perform a physical examination and
develop a differential diagnosis within the limits of their
competence
• Develop a patient management plan taking account of the
particular circumstances of the patient
• Perform some diagnostic tests, therapeutic procedures and
prescribe (subject to legislative changes)
• Request and interpret some diagnostic tests and undertake
patient education, counselling and health promotion
This is a comprehensive range of skills which will be required
of medical care practitioners. It is essential therefore that both
the entry requirements and training programme are rigorous
and intensive. The training programme runs over 90 weeks
with 3150 hours of teaching of which 1600 hours is designated
as clinical learning. This is equivalent to a three year degree
programme. Entrants to the course will be recruited mainly
from science graduates but is also open to existing health
professionals. This is a new profession and it is important that
standards and level of competence is clearly defined which will
enable criteria to be developed for statutory regulation. The
purpose of regulation is to protect the public.
Supervision and governance
A key principle which has been agreed is that a medical care
practitioner will always work under the supervision of a general
practitioner or consultant and will only delegate tasks which
they are competent to perform in accordance with guidance set
out in the General Medical Council’s document, Good Medical
Practice.5 This is similar to the situation of a junior doctor who
whilst accountable for their actions, works under supervision.
The recognition of when a clinical condition is beyond the
expertise of a medical care practitioner is a vital competence
which is discussed and clearly set out in the Competence and
Curriculum Framework. This is essential to safeguard the
public. Medical care practitioners will be trained to work to the
medical model so that they will be able to apply their knowledge
and skills to the needs of the individual patient, rather than
working to pre-determined protocols. The document includes
a model for categorising clinical conditions on the basis of
required competence. Competences are elements performed
to a predetermined standard, which combine to create
professional competence in a defined role.6 Using this model
there are conditions which a medical care practitioner (MCP)
can diagnose and treat; those conditions which when already
diagnosed can then be managed by an MCP; those situations
when referral to the supervising doctor is required and those
conditions which a MCP can monitor which has been diagnosed
and a management plan developed by the supervising doctor.
The experience so far
There are currently 9 medical care practitioner trainees
working in England, in both primary and acute care settings. The
Changing Workforce Programme (now the National Practitioner
Programme) began piloting these roles in South West London
and North West London in 2004. These trainees are undertaking
supervised clinical practice and attend university. The pilot sites
have adapted the role of medical care practitioner according
Malta Medical Journal Volume 18 Issue 01 March 2006
to their local circumstances. The curriculum framework will
in future ensure that medical care practitioners are all trained
to the same standard but then they will be able to adapt their
work in either primary or secondary care according to needs
of the locality.
In 2002, Tipton and Rowley Regis Primary Care Trust in
the Black Country recruited initially three physician assistants
from the United States in response to problems of recruitment
of GPs. These physician assistants are currently unregulated and
responsibility for their actions is taken by the supervising doctor.
Birmingham University Health Services Management Centre
has evaluated this trial.7 They noted that physician assistants
had expanded the skill mix in primary care and worked well in
the primary care team under supervision of the GP. Patients
responded very positively to this new health professional. They
concluded that appropriate regulation is required to allow the
full potential of the role to be realised. The report emphasised
the need to retain the dependent practitioner status as this was
recognised as essential for patient centred care. Stuart and
Catanzaro reviewed the experience of 12 US physician assistants
working in Sandwell, West Midlands.8 They concluded that
the physician assistant model worked well in the UK. They
emphasised the need for high quality educational courses based
on national standards and competences to ensure the credibility
of this new profession in the UK. They suggested that “this group
of practitioners can provide a high standard of care to patients as
well as help to support the medical multidisciplinary team”.
Conclusion
The development of the medical care practitioner role
should benefit both patients and other health professionals.
It will provide an opportunity to further enhance the skill mix
within the primary care and acute secondary care team. This will
allow doctors to be able to spend more time with patients with
multiple complex problems. It will give patients more choice of
healthcare professional and by having a national curriculum and
competence framework medical care practitioners will achieve
a level of competence to agreed national standards helping to
ensure that patients receive high-quality patient centred care.
Further evaluation and research is needed to establish the utility
of the medical care practitioner model.
References
1 Department of Health. The NHS Plan: A plan for investment, a plan
for reform. London: Stationary Office, 2000.
2 Mittman DE, Cawley JF, Fenn WH. Physician Assistants in the
United States. BMJ 2002; 325:485-7.
3 Hutchinson L, Marks T, Pittilo M. The physician assistant: would
the US model meet the needs of the NHS? BMJ 2001; 323:1244-7.
4 The Competence and Curriculum Framework for the Medical Care
Practitioner, Department of Health, 2005.
5 General Medical Council. Good Medical Practice, 3rd edition, London: GMC, 2001
6 Stuart CC. Assessment, supervision and support in clinical practice.
Churchill Livingstone, 2003.
7 Woodin J, McLeod H, McManus R, Jelphs K. The introduction of
US-trained physician assistants to primary care and accident and
emergency departments in Sandwell and Birmingham. Health
Services Management Centre, University of Birmingham, 2005.
8 Stewart A, and Catanzaro R. Can physician assistants be effective in
the UK? Clinical Medicine, 2005; 5:344-8.
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